IntraoperativeIntraoperative Fluid Management Fluid Managementand Blood Transfusion Essentialsand Blood Transfusion Essentials

Glenn P. Gravlee, M.D.Glenn P. Gravlee, M.D.Department of AnesthesiologyDepartment of Anesthesiology

University of Colorado Denver andUniversity of Colorado Denver andHealth Sciences CenterHealth Sciences Center

Body Fluid DistributionBody Fluid Distribution

Perioperative Fluid Perioperative Fluid ““StressorsStressors””

•• NPO status pre-op, intra-op, and post-opNPO status pre-op, intra-op, and post-op•• PatientPatient’’s primary disease causess primary disease causes

intravascular fluid depletion:intravascular fluid depletion:trauma/bleeding, bowel disorderstrauma/bleeding, bowel disorders(obstruction, diarrhea), hyperglycemia(obstruction, diarrhea), hyperglycemiawith osmotic with osmotic diuresisdiuresis, diabetes , diabetes insipidusinsipidus,,poorly controlled hypertension, chronicpoorly controlled hypertension, chronicuse of diureticsuse of diuretics

Perioperative Fluid Stressors (cont)Perioperative Fluid Stressors (cont)

•• PatientPatient’’s primary disease causess primary disease causesintravascular fluid excess: poorlyintravascular fluid excess: poorlycontrolled congestive heart failure, renalcontrolled congestive heart failure, renalfailure overdue for dialysis, pre-failure overdue for dialysis, pre-eclampsiaeclampsia(can go either way (can go either way –– hypovolemiahypovolemia or orhypervolemiahypervolemia))

•• Postoperative nausea or vomiting delaysPostoperative nausea or vomiting delaysresumption of resumption of p.op.o. fluid intake. fluid intake

Perioperative Fluid Perioperative Fluid ““stressorsstressors”” (cont) (cont)

•• IntraoperativeIntraoperative fluid losses can be obvious fluid losses can be obviousor subtleor subtle

•• Obvious: bleeding in surgical fieldObvious: bleeding in surgical field•• Subtle: Evaporative losses from exposedSubtle: Evaporative losses from exposed

peritoneal surfaces, sequestration of fluidperitoneal surfaces, sequestration of fluidin in extravascularextravascular extracellularextracellular space (so- space (so-called called ““third spacingthird spacing””), ), sympathectomysympathectomyfrom spinal or epidural anesthesiafrom spinal or epidural anesthesia

Calculating a Fluid DeficitCalculating a Fluid Deficit

•• Fluid requirement for normal adults:Fluid requirement for normal adults:

Fluids/hour= 60 ml + (Wt in Kg-20)mlFluids/hour= 60 ml + (Wt in Kg-20)ml•• Probably plateaus at 90-100 kg body wt,Probably plateaus at 90-100 kg body wt,

so not more than 140 ml/hrso not more than 140 ml/hr•• Deficit is calculated based on hours of NPODeficit is calculated based on hours of NPO

status: 8 hrs NPO for a 70 kg Pt: 8 Xstatus: 8 hrs NPO for a 70 kg Pt: 8 X(60+60)+ 960 ml(60+60)+ 960 ml

Fluid Deficit (cont)Fluid Deficit (cont)

•• So an 80 kg Pt who has been NPO for 8So an 80 kg Pt who has been NPO for 8hours is almost 1 L behind hours is almost 1 L behind beforebeforeanesthesia and surgeryanesthesia and surgery

•• Replace prior to anesthetic induction?Replace prior to anesthetic induction?Probably OK, but most would replace halfProbably OK, but most would replace halfof it then, and replace the second halfof it then, and replace the second halfover the first hour thereafter (thereover the first hour thereafter (there’’s nos nogold standard)gold standard)

Maintenance FluidsMaintenance Fluids

•• Hourly basal Fluid Requirement isHourly basal Fluid Requirement isapproximately 100-140 ml/hr for mostapproximately 100-140 ml/hr for mostadultsadults

•• Add in blood loss:Add in blood loss:–– Crystalloid replacement (balanced saltCrystalloid replacement (balanced salt

solutions): 3-4 ml of crystalloid per 1 ml ofsolutions): 3-4 ml of crystalloid per 1 ml ofblood lossblood loss

–– Colloid or blood product replacement: 1 ml ofColloid or blood product replacement: 1 ml ofsolution per 1 ml of blood losssolution per 1 ml of blood loss

Third SpacingThird Spacing

•• Controversial SubjectControversial Subject•• Concept is that local trauma causes edema toConcept is that local trauma causes edema to

develop, and that this edema fluid does notdevelop, and that this edema fluid does notmaintain the usual connection betweenmaintain the usual connection betweeninterstitial and intravascular spacesinterstitial and intravascular spaces

•• Greatest third space losses: open Greatest third space losses: open laparotomieslaparotomies(4-6 ml/kg/hr possibly), open thorax with(4-6 ml/kg/hr possibly), open thorax withinflamed pleura (perhaps 2-4 ml/kg/hr)inflamed pleura (perhaps 2-4 ml/kg/hr)

Third Spacing (cont)Third Spacing (cont)

•• Not a big consideration for superficialNot a big consideration for superficial(breast, skin) or peripheral (hand, foot,(breast, skin) or peripheral (hand, foot,knee) procedures: 0-2 ml/kg/hrknee) procedures: 0-2 ml/kg/hr

•• Some believe that the third spacingSome believe that the third spacingconcept is overrated and has givenconcept is overrated and has givenanesthesiologists an excuse foranesthesiologists an excuse foroverloading patients with fluidsoverloading patients with fluids

So is So is third spacingthird spacing overrated? overrated?

•• There probably is There probably is somesome 3 3rdrd spacing, but spacing, butassumed third space formulas for fluid lossesassumed third space formulas for fluid losseshave been too high (e.g., maybe it peaks at 3-4have been too high (e.g., maybe it peaks at 3-4ml/kg/hr, and perhaps only when the bowelml/kg/hr, and perhaps only when the bowelserosalserosal surfaces are fully surfaces are fully ““exposedexposed””))

-Some have assumed as much as 8-10 ml/kg/hr-Some have assumed as much as 8-10 ml/kg/hrunder these conditions: TOO HIGHunder these conditions: TOO HIGH

•• Recent studies suggests that conservative fluidRecent studies suggests that conservative fluidmanagement improves outcomes with colon andmanagement improves outcomes with colon andpulmonary resections (others yet to come?)pulmonary resections (others yet to come?)

Rational Fluid Management Plan forRational Fluid Management Plan fora 70 kg man undergoing an opena 70 kg man undergoing an opensmall bowel resection small bowel resection –– NPO for 6 NPO for 6

hourshours

•• Fluid deficit: 110 ml/hr X 6 hrs = 660 mlFluid deficit: 110 ml/hr X 6 hrs = 660 ml•• Give approx 350 ml of LR pre-inductionGive approx 350 ml of LR pre-induction•• 11stst hour: Maintenance (110 ml) plus hour: Maintenance (110 ml) plus

remaining deficit (~300 ml) plus approx 4remaining deficit (~300 ml) plus approx 4ml/kg/hr 3ml/kg/hr 3rdrd space deficit (280 ml) = 690 space deficit (280 ml) = 690mlml

Rational Fluid Management Plan for aRational Fluid Management Plan for a70 kg man undergoing an open small70 kg man undergoing an open small

bowel resection bowel resection –– NPO for 6 hours NPO for 6 hours•• Second hour: Assume 100 ml blood loss:Second hour: Assume 100 ml blood loss: Maintenance (110 ml) plus 3Maintenance (110 ml) plus 3rdrd space loss (280 space loss (280

ml) plus 4 X 100 ml to replace blood loss = 790ml) plus 4 X 100 ml to replace blood loss = 790mlml

•• If the bowel is not fully exposed to the room (itIf the bowel is not fully exposed to the room (it’’ssin a bag or itin a bag or it’’s sequestered intra-abdominally),s sequestered intra-abdominally),decrease the 3decrease the 3rdrd space assumption space assumption

•• Laparoscopic approach greatly decreases 3Laparoscopic approach greatly decreases 3rdrd

spacing: probably 2 ml/kg/hr or lessspacing: probably 2 ml/kg/hr or less

And donAnd don’’t forget:t forget:

Urine output counts in the fluidUrine output counts in the fluidloss category: replace 1:1 withloss category: replace 1:1 with

crystalloidcrystalloid

CrystalloidsCrystalloids

•• Approximately 25% remains intravascularApproximately 25% remains intravascular1 hour after administration1 hour after administration

•• Even less with D5W (<10%)Even less with D5W (<10%)•• Typically Normal Saline or Typically Normal Saline or ““balanced saltbalanced salt

solutionssolutions”” are used are used intraoperativelyintraoperatively in inadultsadults

•• Balanced Salt Solutions: lactated RingersBalanced Salt Solutions: lactated Ringers(LR) or (LR) or NormosolNormosol-R (similar to -R (similar to PlasmalytePlasmalyte))

Crystalloid CompositionCrystalloid Composition

5.05.0108108140140NormosolNormosol-R-R

4.04.0109109130130L.R.L.R.

001541541541540.9% N.S.0.9% N.S.

000000D5WD5W

KKClClNaNaFluidFluid

Crystalloid CompositionCrystalloid Composition

Mg 3,Mg 3,Acetate 27,Acetate 27,GluconateGluconate 23 23

6.66.6294294NormosolNormosol-R-R

Lactate 28,Lactate 28,Calcium 3Calcium 3

6.56.5273273L.R.L.R.

6.06.03083080.9% N.S.0.9% N.S.

4.54.5252252D5WD5W

OtherOtherpHpHOsmOsmFluidFluid

Which Crystalloid to Select?Which Crystalloid to Select?

•• D5W?D5W? Seldom used, but makes sense as Seldom used, but makes sense as““backgroundbackground”” maintenance for diabetics on maintenance for diabetics oninsulin, children, and adults undergoing longinsulin, children, and adults undergoing longcases (>6-8 hrs). Useless for intravascularcases (>6-8 hrs). Useless for intravascularvolume replacementvolume replacement

•• N.S.?N.S.? Makes sense if Pt is Makes sense if Pt is hyperkalemichyperkalemic,,hyponatremichyponatremic, , hypochloremichypochloremic, or if slight, or if slighthyperosmolarityhyperosmolarity is desired (craniotomies), not so is desired (craniotomies), not sogood if avoidance of metabolic acidosis isgood if avoidance of metabolic acidosis isimportantimportant

Which crystalloid to select?Which crystalloid to select?

•• LR: LR: Workhorse solution in most Workhorse solution in most ORsORs,,avoid if avoid if hyperkalemichyperkalemic or or hypercalcemichypercalcemic,,tends to induce mild alkalosistends to induce mild alkalosis

•• NormosolNormosol-R: -R: Similar to LR. Mg is a plus,Similar to LR. Mg is a plus,absence of Ca allows mixing with citratedabsence of Ca allows mixing with citratedblood productsblood products

Special Situation: BurnsSpecial Situation: Burns

•• Parkland Formula: 2 ml/kg/% BSA burn overParkland Formula: 2 ml/kg/% BSA burn overfirst 8 hours (0.25 ml/kg/% burn/hr), samefirst 8 hours (0.25 ml/kg/% burn/hr), sameamount over next 16 hours (0.125ml/kg/% BSAamount over next 16 hours (0.125ml/kg/% BSAburn/hr)burn/hr)

•• Calculation for 80 kg Pt with 50% BSA burnCalculation for 80 kg Pt with 50% BSA burncoming to OR for coming to OR for debridementdebridement 12 hours after 12 hours afterinjury:injury:–– 0.125 X 80 X 50= 500 ml/hr for burn alone0.125 X 80 X 50= 500 ml/hr for burn alone

•• DonDon’’t forget maintenance, blood loss, possiblet forget maintenance, blood loss, possiblefebrile state (increase fluids), and urine output!febrile state (increase fluids), and urine output!

Introduction to TransfusionIntroduction to Transfusion

RBCsRBCs, FFP, and Platelet, FFP, and PlateletConcentratesConcentrates

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Blood Component Blood Component ““ProductionProduction””

Therapeutic DilemmaTherapeutic DilemmaAnemia is badAnemia is bad•• Increases mortalityIncreases mortality•• Decreases Quality of LifeDecreases Quality of Life•• Jeopardizes organJeopardizes organ

viability, especially inviability, especially inpresence of limitedpresence of limitedcollateral or collateral or vasodilatoryvasodilatoryreserve (critical coronaryreserve (critical coronaryor carotid or carotid stenosesstenoses))

Transfusion is badTransfusion is bad•• Independent associationIndependent association

with increased mortalitywith increased mortalityand morbidityand morbidity

•• ImmunosuppressionImmunosuppression and andenhanced inflammationenhanced inflammationmay be the culprit may be the culprit ––leukoreductionleukoreduction may help may help

•• Immediate augmentationImmediate augmentationof of OO22 transport may be transport may belimited (2,3 DPG deficit)limited (2,3 DPG deficit)

•• Infectious complicationsInfectious complications

Infectious Complications ofInfectious Complications ofTransfusionTransfusion

1/100*1/100*CytomegalovirusCytomegalovirus

1/200,0001/200,000Hepatitis BHepatitis B

1/600,0001/600,000Hepatitis CHepatitis C

1/600,0001/600,000HTLV 1 or 2HTLV 1 or 2

1/800,0001/800,000HIVHIV

Risk (in most of USA)Risk (in most of USA)InfectionInfection

* As high as 1/3 if immunosuppressed

Other infectious complications ofOther infectious complications oftransfusiontransfusion

•• Viruses: West Nile (1/26,000 estimate),Viruses: West Nile (1/26,000 estimate),CreutzfeldtCreutzfeldt-Jacob (rare)-Jacob (rare)

•• Bacteria: Unusual, but as high as 1/1000 inBacteria: Unusual, but as high as 1/1000 inplatelet concentrates and usually fatalplatelet concentrates and usually fatal

•• Parasites: Malaria, Parasites: Malaria, babesiosisbabesiosis (like Malaria), and (like Malaria), andChagaChaga’’ss Disease with regional variation, even in Disease with regional variation, even inUSA, but rare overallUSA, but rare overall

•• One never knows what new and unsuspectedOne never knows what new and unsuspectedvirus is lurking in the blood supply. Hepatitis Cvirus is lurking in the blood supply. Hepatitis Cwent virtually undetected for almost a decade atwent virtually undetected for almost a decade atan incidence of an incidence of 4% per unit transfused4% per unit transfused!!

Immunologic Complications ofImmunologic Complications ofTransfusionTransfusion

Mild and relatively commonMild and relatively common•• UrticariaUrticaria•• Febrile reactionsFebrile reactions•• ““GenericGeneric”” immunoimmuno--

suppression suppression –– not notnecessarily mild necessarily mild –– assoc. assoc.with cancer recurrencewith cancer recurrenceand infectionsand infections

Serious and uncommonSerious and uncommon•• ABO/ABO/RhRh incompatibility incompatibility•• Non-ABO antibodies:Non-ABO antibodies:

hemolysishemolysis often delayed often delayed•• TRALI: can be fatalTRALI: can be fatal•• Anaphylaxis: usuallyAnaphylaxis: usually

recipient has an recipient has an IgAIgAdeficiencydeficiency

Metabolic Complications ofMetabolic Complications ofTransfusionTransfusion

•• Citrate intoxication (FFP given very fast isCitrate intoxication (FFP given very fast ismost common cause): Rx Calcium chloridemost common cause): Rx Calcium chloride

•• HyperkalemiaHyperkalemia: older : older RBCsRBCs typically, Rx as typically, Rx ashyperkalemiahyperkalemia

•• HypokalemiaHypokalemia, metabolic acidosis,, metabolic acidosis,metabolic alkalosismetabolic alkalosis

•• Hypothermia if RBC warming is ineffectiveHypothermia if RBC warming is ineffective–– not an issue with FFP or platelets not an issue with FFP or platelets

Most Important Transfusion PredictorMost Important Transfusion Predictor

PreoperativePreoperativeHgb/HctHgb/Hct

Anemia in Elective Surgical PatientsAnemia in Elective Surgical PatientsGoodnoughGoodnough LT, LT, AnesthAnesth AnalgAnalg 2005;101:1858-61 2005;101:1858-61

•• Expert panel evaluating best practicesExpert panel evaluating best practices•• Recommendation 1Recommendation 1: Elective surgical Pts: Elective surgical Pts

should have should have HgbHgb level tested a minimum level tested a minimumof 30 days before scheduled surgeryof 30 days before scheduled surgery

•• Recommendation 2: Recommendation 2: Unexplained anemiaUnexplained anemiashould be considered secondary to someshould be considered secondary to someother process, and elective surgery shouldother process, and elective surgery shouldbe deferred until an appropriate diagnosisbe deferred until an appropriate diagnosisis madeis made

Copyright restrictions apply.Goodnough, L. T. et al. Anesth Analg 2005;101:1858-1861

Anemia Diagnostic Work-upAnemia Diagnostic Work-up

So So GoodnoughGoodnough et al. are et al. arerecommending that we Diagnoserecommending that we Diagnose

and Treat anemia and Treat anemia preoperatively!preoperatively!

•• Does this seem like rocket science?Does this seem like rocket science?•• NuhNuh-uh, but it is seldom done by surgeons-uh, but it is seldom done by surgeons

and anesthesiologists. Why?and anesthesiologists. Why?•• Often impractical. Depends onOften impractical. Depends on

–– 1. Surgical urgency1. Surgical urgency–– 2. Access to patients pre-op2. Access to patients pre-op–– 3. Timing of access to patients pre-op3. Timing of access to patients pre-op

Clinical Settings Where Pre-opClinical Settings Where Pre-opDxDx/Rx of anemia works or doesn/Rx of anemia works or doesn’’tt

It worksIt works•• Elective total jointsElective total joints•• Elective cardiac valveElective cardiac valve

replacement/repairreplacement/repair•• Spine fusions orSpine fusions or

scoliosis repairsscoliosis repairs•• Most radicalMost radical

hysterectomies orhysterectomies orradical radical prostatectomiesprostatectomies

It doesnIt doesn’’t work (or isnt work (or isn’’ttneeded)needed)

•• Urgent CABGUrgent CABG•• Fast-growing cancers,Fast-growing cancers,

even though even though ““electiveelective””•• Procedures whereProcedures where

transfusion is unlikelytransfusion is unlikely

ASA Practice GuidelinesASA Practice Guidelines

•• Transfusion rarely indicated when Transfusion rarely indicated when HgbHgb >>10 10 g/dLg/dL

•• Transfusion almost always indicated withTransfusion almost always indicated withHgbHgb << 6 6 g/dLg/dL

•• At levels between 6 and 10, it dependsAt levels between 6 and 10, it dependsupon the situationupon the situation

•• Use of a universal Use of a universal ““transfusion triggertransfusion trigger”” is isnot recommendednot recommended

Don Don’’t be Trigger Happyt be Trigger Happy

Transfusion Transfusion ““triggertrigger”” isn isn’’t just a numericalt just a numericalthreshold: Consider threshold: Consider ““Patient PerformancePatient Performance””markers: tachycardia, fatigue (if awake)markers: tachycardia, fatigue (if awake)

•• Myocardial ischemia: ECG, TEEMyocardial ischemia: ECG, TEE•• Increased susceptibility: LVH, CAD,Increased susceptibility: LVH, CAD,

CerebrovascCerebrovasc. . DzDz, hyperthermia,, hyperthermia,hypermetabolichypermetabolic states (burns, sepsis) states (burns, sepsis)

•• Evidence of global OEvidence of global O22 delivery failure: delivery failure:SvOSvO22/PvO/PvO22, lactic acidosis, lactic acidosis

RBC Transfusion ModifiersRBC Transfusion Modifiers

Primary anemia compensation is increasedPrimary anemia compensation is increasedcardiac output, so this fails ifcardiac output, so this fails if

•• The heart canThe heart can’’t increase CO (bad valvet increase CO (bad valvedisease, severe diastolic dysfunction,disease, severe diastolic dysfunction,dilated dilated cardiomyopathycardiomyopathy, etc.), etc.)

•• You canYou can’’t maintain t maintain normovolemianormovolemia: rapid: rapidblood lossblood loss

•• In those situations, In those situations, HgbHgb 8-9 may be a 8-9 may be agood good ““trigger pointtrigger point”” for RBC transfusion for RBC transfusion

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Bleeding/Bleeding/coagulopathycoagulopathy algorithm algorithm

Indications for Fresh-frozen plasmaIndications for Fresh-frozen plasma

•• Correction of Correction of microvascularmicrovascular bleeding with bleeding withelevated PT or PTT (>1.5 x normal)elevated PT or PTT (>1.5 x normal)

•• Correction of congenital or acquired factorCorrection of congenital or acquired factordeficiencies that lack specific concentratesdeficiencies that lack specific concentrates

•• Urgent reversal of Urgent reversal of warfarinwarfarin-induced-inducedanticoagulationanticoagulation

•• Rare: exchange transfusion for autoimmuneRare: exchange transfusion for autoimmunediseases, diseases, angioneuroticangioneurotic edema (C5a deficiency) edema (C5a deficiency)

•• NonindicationsNonindications: Fixed ratio to RBC: Fixed ratio to RBCtransfusion, malnutritiontransfusion, malnutrition

FFP: So misunderstoodFFP: So misunderstoodThe Dr. Pepper of blood productsThe Dr. Pepper of blood products

•• Most Most overtransfusedovertransfused blood component blood component–– Problem exacerbated by lack of rapidProblem exacerbated by lack of rapid

turnaround on PT and PTT testingturnaround on PT and PTT testing

•• And yet when FFP is truly needed, manyAnd yet when FFP is truly needed, manydocs docs underdoseunderdose itit–– Usual starting dose for Usual starting dose for microvascularmicrovascular bleeding bleeding

with elevated PT is 10-15 ml/kg, i.e., 4-6 unitswith elevated PT is 10-15 ml/kg, i.e., 4-6 unitsin most adultsin most adults

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Fibrinogen concentration Fibrinogen concentration vsvs blood bloodvolumes lost (similar for other factors)volumes lost (similar for other factors)

Implication: Critical deficiency (<100) seldom reached at < 1 BV

Platelet Transfusion IndicationsPlatelet Transfusion Indications

•• NonsurgicalNonsurgical Pt: Pt: PltPlt Count < 20,000 (some Count < 20,000 (somesay 10,000)say 10,000)

•• Surgical Pt: Surgical Pt: PltPlt Count < 50,000 pre- Count < 50,000 pre-operatively or operatively or intraoperativelyintraoperatively

•• Platelet dysfunction (as in afterPlatelet dysfunction (as in aftercardiopulmonary bypass): potentiallycardiopulmonary bypass): potentiallyneeded even if needed even if PltPlt count is 100,000, but count is 100,000, butseldom if higher than thatseldom if higher than that

Platelet transfusion wonPlatelet transfusion won’’t help int help in

•• Heparin-induced thrombocytopenia (aHeparin-induced thrombocytopenia (aHYPERCOAGULABLE state exacerbated byHYPERCOAGULABLE state exacerbated byPltsPlts), TTP (ditto)), TTP (ditto)

•• ITP: The circulating antibodies just eat theITP: The circulating antibodies just eat thetransfused platelets: risk>>benefittransfused platelets: risk>>benefit

•• MAY not help if there is unboundMAY not help if there is unboundclopidogrelclopidogrel or or abciximababciximab in the plasma in the plasma

Platelet transfusion dosingPlatelet transfusion dosing

•• Usually start with 0.1 unit/kg: platelet countUsually start with 0.1 unit/kg: platelet countshould increase by 10,000 per unitshould increase by 10,000 per unit

•• Check the size of a pooled platelet pack at yourCheck the size of a pooled platelet pack at yourhospital (ranges from 4-8 units, and folks oftenhospital (ranges from 4-8 units, and folks oftenmistakenly call this 1 mistakenly call this 1 ““unitunit”” of platelets locally) of platelets locally)

•• Single donor Single donor plateletpheresisplateletpheresis: used for high-risk: used for high-riskrecipients, 1 recipients, 1 pheresispheresis is about the same as 6-8 is about the same as 6-8pooled units of random donor plateletspooled units of random donor platelets